Healthcare Provider Details

I. General information

NPI: 1750864799
Provider Name (Legal Business Name): IYABO MERCY OMIDIWURA APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SUGAR GROVE BLVD STE 250
STAFFORD TX
77477-2639
US

IV. Provider business mailing address

4800 SUGAR GROVE BLVD STE 250
STAFFORD TX
77477-2639
US

V. Phone/Fax

Practice location:
  • Phone: 832-554-6773
  • Fax:
Mailing address:
  • Phone: 832-554-6773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number952285
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1100163
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAC008119
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: